Investigations Analyst plays a key role in safeguarding healthcare integrity by conducting in-depth, confidential inquiries into potential fraud, waste, and abuse. You will analyze medical claims data, identify irregular patterns, and determine appropriate investigative follow-up, including pre-payment interventions. Your work ensures compliance with federal and state healthcare regulations while supporting accurate claims processing.
Key Responsibilities
- Conduct and document thorough investigations into suspected healthcare fraud, ensuring alignment with legal and regulatory standards
- Review medical claims to detect anomalies and patterns indicative of misuse or improper billing
- Request and evaluate medical records from providers to validate claims and support investigative conclusions
- Communicate clearly with healthcare providers, internal teams, and external agencies via phone and email
- Prepare detailed written reports and support actions such as claim flagging or escalation to enforcement bodies
Qualifications
Successful candidates will have:
- High School Diploma or GED, or higher education
- Minimum of three years of experience in healthcare investigations, managed care, insurance, legal, or law enforcement settings
- Proven experience processing medical claims and investigating fraud, particularly in healthcare systems
- Strong written and verbal communication skills, with the ability to explain complex findings to diverse audiences
Preferred Background
- Bachelor’s degree in Criminal Justice or a related field
- Experience with Medicare, Medicaid, Medicare Advantage, Part D, Tricare, or commercial insurance regulations
- Familiarity with claims systems such as Facets, iDRS, CSP, or Macess
- Healthcare Coding Certification, Certified Fraud Examiner (CFE), or accredited Healthcare Fraud Investigator (AHFI) credential
Work Environment
This position offers full-time telecommute flexibility for candidates located anywhere in the U.S. You will work within a structured, compliance-driven environment focused on health equity, regulatory adherence, and continuous professional development.
Compensation & Benefits
Salary ranges from $60,200 to $107,400 annually, based on experience and location. Additional offerings include equity stock purchase options, incentive programs, and employer contributions to a 401k plan. Comprehensive health and wellness benefits are provided, along with career advancement opportunities.
Commitment to Inclusion & Compliance
We are an Equal Employment Opportunity employer. All qualified applicants receive fair consideration for employment regardless of race, religion, age, color, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics under applicable laws. We maintain a drug-free workplace, and employment is contingent upon passing a drug screening. In accordance with the San Francisco Fair Chance Ordinance, we consider qualified applicants with arrest and conviction records.
